Appointment Request

Appointment Request

For URGENT requests needing to be seen within 24-48 hours, please call our appointment line directly at (770) 271-9857.
New PatientReturning Patient
Name*

First NameLast Name
Birth Date*

MonthDayYear
At what phone number would you like to be contacted about your appointment/?*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
If using insurance, what insurance carrier and/or plan do you have?
If no insurance, or if you are unsure, leave blank.
OPTIONAL: If available, please upload a photo copy of your insurance card so we can verify your benefits.

All images are uploaded onto a HIPAA-Compliant, secure platform. Insurance information will not be used, dispersed, or distributed for any reason other than for verification and filing purposes.
Cancelof
Which physician do you currently see, or which physician would you like to make an appointment with?
If you do not have a specific physician in mind, please select "No Preference/First Available"
Preferred office location:
If you do not have a specific location in mind, or are willing to travel to be seen, please select "No Preference/First Available"
Preferred language:
*PLEASE NOTE* While we make every effort to accommodate requests for translation, we cannot guarantee a medical interpreter will be available for your preferred date/time. We respectfully request that all patients requiring translation bring a family, friend, or interpreter with them if at all possible.
ShoulderElbowWristHand/FingersHipKneeAnkleFootOther
NoYes, my condition is due to a motor vehicle accident.Yes, my condition is due to a worker's compensation claim.
Are there any other details specific to scheduling your appointment that we should know about?
Should be Empty: